ABSTRACT

Title

Significant differences in sleep and depression among chronic pain groups: Implications for patient education

Purpose

PURPOSE/HYPOTHESIS
Chronic pain (CP) is a widespread and costly condition, affecting nearly 100 million Americans and costing over $600 billion annually. Evidence suggests that compared to healthy controls (HC), chronic pain populations experience problems with sleep and depression. Less understood is how whether these problems are differentially experienced by different chronic pain conditions (i.e., chronic low back pain and fibrimyalgia). To address this questions, questionnaire data regarding sleep, depression and pain were collected.

Subjects

NUMBER OF SUBJECTS
For this study, participants were recruited from the Columbia, Missouri community and surrounding small towns (Ashland, Booneville, and Moberly). Recruitment flyers were posted in clinics that often treat chronic pain diseases and on a weekly news bulletin email distributed to faculty, staff, and students affiliated with MU or university hospital. For the CLBP group, inclusionary criteria were established to incorporate individuals (1) experiencing CLBP for greater than the past 6 months that fulfills at least one of Quebec Task Force and Spinal Disorders diagnostic criteria, (2) no history of a severe psychological or neuropsychological disorder, Specific criteria for the HC group included (1) no history of chronic pain, severe psychological or neuropsychological disorder,

For all groups, potential participants were excluded if (1) they could not refrain from usage of analgesics the day before and of their scan, (2) tested positive on a pre-MRI metal screening, (3) were pregnant, (4) and/or did not display pain symptoms consistent with Quebec Task Force and Spinal Disorders diagnostic criteria.

All participants for this study provided written consent. Data was collected from 158 participants (HC = 50, 27 females); CLBP = 64, 41 females; FM = 44, 39 females). This study was approved by the Institutional Review Board at the University of Missouri.

Methods

MATERIALS AND METHODS
As part of the study, participants completed a variety of questionnaires that assessed pain, sleep and affect. Specifically, participants completed the Beck Depression Inventory-II (BDI-II), Epworth Sleepiness Scale, McGill-Melzack Pain Questionnaire and Pittsburg Sleep Quality Index (PSQI). A subgroup of participantas also completed the Insomnia Severity Index.

Results

RESULTS
An ANOVA with Tukey Honest Significant Differences (TukeyHSD) testing was carried out using RStudio (Version 1.2.5033). The overall test for a main effect of group was significant for all but three variables (i.e., Sleef Effiency, Daytime Dysfunction and Total Time in Bed). PostHoc follow up testing using TukeyHSD revealed the presence of significant group differences for all but the same two variables listed above. However, the FM-HC comparison trended toward significance with p ≤ 0.07.

Conclusions

CONCLUSIONS

Clinical Relevance

CLINICAL RELEVANCE
This study supported by NINR grant #R01NR015314

GOALS

Questions asked for this study

Q1: What is the correlation between sleep and pain measures?
* Correlation

Q2: Controlling for pain, is there a difference in sleep variables?
* ANCOVA
* Regression

NOTE Add mean and SD for the variables.

MEASURES

Pittsburg Sleep Questionnaire
Epsworth Sleepiness Scale
Insomnia Severity Index
McGill Pain Questionnaire
Beck Depression Inventory

DATA

Import data from GitHub

PSQI

The global PSQI score is then calculated by totaling the seven component scores, providing an overall score ranging from 0 to 21, where lower scores denote a healthier sleep quality.
A PSQI Global score ≥ 5 is the clinical cutoff score (i.e., sleep problems)
The PSQI data has been updated, processed, clean and scored
NOTE: I need to add a section that discusses the PSQI cutoff. Anything over “5” is considered significant.

INITIAL DATA SETS

Create a small dataset (dat.sm) that includes only the variables of interest.

VARIANCE CHECK

Which variable(s) in the dat.sm data has potential issues with variances?

[1] "slpDist"

SAMPLE DESCRIPTIVES

Group by sex for overall sample.

Entire Sample
	Sex
Group	Female	Male	Total
HC	27	23	50
CLBP	41	23	64
FM	39	5	44
Total	107	51	158

Means and SDs for each group.


 Descriptive statistics by group 
group: HC
              vars  n mean   sd   se
group.factor*    1 50 1.00 0.00 0.00
slpQual          2 50 0.76 0.62 0.09
slpLat           3 50 0.94 0.79 0.11
slpDur           4 50 0.80 0.70 0.10
slpEff           5 50 1.32 1.35 0.19
slpDayFcn        6 50 0.30 0.46 0.07
psqi_Global      7 50 5.38 2.70 0.38
ess_total        8 50 5.90 2.84 0.40
bdi_total        9 50 3.26 4.04 0.57
mcgill_total    10 50 1.56 6.20 0.88
------------------------------------------------------------ 
group: CLBP
              vars  n  mean    sd   se
group.factor*    1 64  2.00  0.00 0.00
slpQual          2 64  1.20  0.78 0.10
slpLat           3 64  1.28  0.83 0.10
slpDur           4 64  0.86  0.71 0.09
slpEff           5 64  1.33  1.31 0.16
slpDayFcn        6 64  0.22  0.42 0.05
psqi_Global      7 64  6.47  2.83 0.35
ess_total        8 64  6.88  3.48 0.44
bdi_total        9 64 10.12  8.60 1.08
mcgill_total    10 64 24.94 14.93 1.87
------------------------------------------------------------ 
group: FM
              vars  n  mean    sd   se
group.factor*    1 44  3.00  0.00 0.00
slpQual          2 44  1.77  0.74 0.11
slpLat           3 44  2.11  1.04 0.16
slpDur           4 44  1.43  1.00 0.15
slpEff           5 44  1.68  1.33 0.20
slpDayFcn        6 44  0.11  0.32 0.05
psqi_Global      7 44  9.75  3.86 0.58
ess_total        8 44  8.23  4.05 0.61
bdi_total        9 44 16.11  9.31 1.40
mcgill_total    10 44 35.57 13.12 1.98
------------------------------------------------------------ 
group: TRUE
NULL

CORRELATIONS

CORR PLOTS

PLOTS

BAR PLOTS

The end of corr plots

Warning: `select_()` is deprecated as of dplyr 0.7.0.
Please use `select()` instead.
This warning is displayed once every 8 hours.
Call `lifecycle::last_warnings()` to see where this warning was generated.

Warning: `tbl_df()` is deprecated as of dplyr 1.0.0.
Please use `tibble::as_tibble()` instead.
This warning is displayed once every 8 hours.
Call `lifecycle::last_warnings()` to see where this warning was generated.

# A tibble: 3 x 8
  .y.          group1 group2        p    p.adj p.format p.signif method
  <chr>        <chr>  <chr>     <dbl>    <dbl> <chr>    <chr>    <chr> 
1 mcgill_total .all.  HC     7.11e-23 2.10e-22 <2e-16   ****     T-test
2 mcgill_total .all.  CLBP   6.29e- 2 6.30e- 2 0.063    ns       T-test
3 mcgill_total .all.  FM     1.97e- 8 3.90e- 8 2e-08    ****     T-test

Warning: `group_by_()` is deprecated as of dplyr 0.7.0.
Please use `group_by()` instead.
See vignette('programming') for more help
This warning is displayed once every 8 hours.
Call `lifecycle::last_warnings()` to see where this warning was generated.

geom_signif: na.rm = FALSE, parse = FALSE
stat_signif: na.rm = FALSE, comparisons = list(c("S1", "S2")), test = wilcox.test, test.args = NULL, annotations = ***, map_signif_level = FALSE, y_position = 9.3, xmin = NULL, xmax = NULL, margin_top = 0.05, step_increase = 0, tip_length = 0, manual = FALSE
position_identity

ANOVA (Main effect of group)

ANOVA full model
Name	p.value
slpQual	1.87e-09
slpLat	4.37e-09
slpDur	0.000197
slpEff	0.318
slpDist	0.0365
slpMeds	9.37e-09
slpDayFcn	0.0906
psqi_Global	4.43e-10
ess_total	0.00597
isi_total	7.57e-10
bdi_total	1.29e-12
mcgill_total	4.96e-28
TIB	0.865
Note:
Red = Significant main effect for group (p ≤ 0.05)

ANOVA full model with raw scores
Name	p.value
slpQualraw	1.87e-09
slpLatraw	5.36e-08
slpDurraw	0.0013
slpEffraw	0.695
slpDistraw	6.09e-18
slpMedsraw	9.37e-09
slpDayFcnraw	9.76e-12
psqi_Globalraw	1.71e-05
ess_total	0.00597
isi_total	7.57e-10
bdi_total	1.29e-12
mcgill_total	4.96e-28
TIB	0.865
Note:
Red = Significant main effect for group (p ≤ 0.05)

POSTHOC

PostHoc group comparisons: **See** *Note* at table end
comparison	diff	conf.low	conf.high	adj.p.value
Sleep Quality
CLBP-HC	0.443	0.120	0.766	0.00411
FM-HC	1.013	0.659	1.367	7.56e-10
FM-CLBP	0.570	0.234	0.905	0.000268
Sleep Latency
CLBP-HC	0.341	-0.052	0.735	0.103
FM-HC	1.174	0.743	1.604	4.1e-09
FM-CLBP	0.832	0.424	1.240	9.81e-06
Sleep Duration
CLBP-HC	0.059	-0.297	0.415	0.918
FM-HC	0.632	0.242	1.022	0.000535
FM-CLBP	0.572	0.203	0.942	0.00098
Sleep Efficacy
CLBP-HC	0.008	-0.584	0.600	0.999
FM-HC	0.362	-0.287	1.010	0.386
FM-CLBP	0.354	-0.261	0.968	0.363
Sleep Disturbance
CLBP-HC	0.060	-0.000	0.120	0.0512
FM-HC	0.060	-0.006	0.126	0.0829
FM-CLBP	0.000	-0.063	0.063	1
Sleep Medications
CLBP-HC	0.258	-0.208	0.724	0.391
FM-HC	1.316	0.806	1.827	2.38e-08
FM-CLBP	1.058	0.575	1.542	2.03e-06
Sleep Daytime Functioning
CLBP-HC	-0.081	-0.264	0.101	0.544
FM-HC	-0.186	-0.386	0.013	0.0732
FM-CLBP	-0.105	-0.294	0.084	0.39
PSQI Global
CLBP-HC	1.089	-0.303	2.480	0.156
FM-HC	4.370	2.846	5.894	6.86e-10
FM-CLBP	3.281	1.838	4.725	8.11e-07
ESS Total
CLBP-HC	0.975	-0.574	2.524	0.299
FM-HC	2.327	0.631	4.023	0.00406
FM-CLBP	1.352	-0.255	2.959	0.118
ISI Total
CLBP-HC	4.171	0.547	7.794	0.0199
FM-HC	10.250	6.728	13.772	2.19e-09
FM-CLBP	6.079	3.080	9.079	1.64e-05
BDI Total
CLBP-HC	6.865	3.426	10.304	1.53e-05
FM-HC	12.854	9.087	16.620	5.43e-13
FM-CLBP	5.989	2.420	9.557	0.00032
McGill Total
CLBP-HC	23.378	17.897	28.858	1.42e-14
FM-HC	34.008	28.006	40.010	0
FM-CLBP	10.631	4.944	16.317	5.38e-05
Time in Bed
CLBP-HC	-0.439	-5.355	4.476	0.976
FM-HC	-1.215	-6.598	4.168	0.855
FM-CLBP	-0.776	-5.876	4.324	0.931
Note:
Red = Significant group tests (p ≤ 0.05)

PostHoc (PSQI raw) group comparisons: **See** *Note* at table end
comparison	diff	conf.low	conf.high	adj.p.value
Sleep Quality raw
CLBP-HC	0.443	0.120	0.766	0.00411
FM-HC	1.013	0.659	1.367	7.56e-10
FM-CLBP	0.570	0.234	0.905	0.000268
Sleep Latency raw
CLBP-HC	6.502	-4.155	17.159	0.321
FM-HC	28.805	17.135	40.476	8.85e-08
FM-CLBP	22.303	11.246	33.361	1.24e-05
Sleep Duration raw
CLBP-HC	-0.163	-0.699	0.374	0.753
FM-HC	-0.871	-1.459	-0.283	0.00171
FM-CLBP	-0.708	-1.265	-0.151	0.00853
Sleep Efficacy raw
CLBP-HC	-0.287	-14.557	13.983	0.999
FM-HC	-4.998	-20.626	10.631	0.73
FM-CLBP	-4.711	-19.517	10.096	0.732
Sleep Disturbance raw
CLBP-HC	5.026	3.150	6.903	7.24e-09
FM-HC	8.756	6.701	10.812	1.45e-14
FM-CLBP	3.730	1.783	5.677	3.43e-05
Sleep Medications raw
CLBP-HC	0.258	-0.208	0.724	0.391
FM-HC	1.316	0.806	1.827	2.38e-08
FM-CLBP	1.058	0.575	1.542	2.03e-06
Sleep Daytime Functioning raw
CLBP-HC	0.703	0.096	1.309	0.0187
FM-HC	2.140	1.476	2.804	6.9e-12
FM-CLBP	1.438	0.808	2.067	7.15e-07
PSQI Global raw
CLBP-HC	12.482	-3.805	28.770	0.168
FM-HC	36.162	18.325	54.000	1.11e-05
FM-CLBP	23.680	6.781	40.579	0.00325
ESS Total
CLBP-HC	0.975	-0.574	2.524	0.299
FM-HC	2.327	0.631	4.023	0.00406
FM-CLBP	1.352	-0.255	2.959	0.118
ISI Total
CLBP-HC	4.171	0.547	7.794	0.0199
FM-HC	10.250	6.728	13.772	2.19e-09
FM-CLBP	6.079	3.080	9.079	1.64e-05
BDI Total
CLBP-HC	6.865	3.426	10.304	1.53e-05
FM-HC	12.854	9.087	16.620	5.43e-13
FM-CLBP	5.989	2.420	9.557	0.00032
McGill Total
CLBP-HC	23.378	17.897	28.858	1.42e-14
FM-HC	34.008	28.006	40.010	0
FM-CLBP	10.631	4.944	16.317	5.38e-05
Time in Bed
CLBP-HC	-0.439	-5.355	4.476	0.976
FM-HC	-1.215	-6.598	4.168	0.855
FM-CLBP	-0.776	-5.876	4.324	0.931
Note:
Red = Significant group tests (p ≤ 0.05)

ISI ANALYSES

This set of analyses uses a subset of subjects who have completed the ISI

Also create a dataset of subjects with ISI data (dat.isi).

DATA VARIANCE

The variable(s) in the ISI data with variance issues are:

character(0)

ISI subgroup ANOVA full model
Name	p.value
slpQual	4.01e-05
slpLat	0.00123
slpDur	0.00795
slpEff	0.353
slpDist	0.022
slpMeds	0.000275
slpDayFcn	0.0846
psqi_Global	6.43e-05
ess_total	0.0723
isi_total	7.57e-10
bdi_total	3.49e-06
mcgill_total	1.24e-14
TIB	0.383
Note:
Red = Significant main effect for group (p ≤ 0.05)

PostHoc group comparisons: **See** *Note* at table end
comparison	diff	conf.low	conf.high	adj.p.value
Sleep Quality
CLBP-HC	0.465	-0.022	0.951	0.0644
FM-HC	0.925	0.452	1.398	3.18e-05
FM-CLBP	0.460	0.058	0.863	0.021
Sleep Latency
CLBP-HC	0.312	-0.356	0.979	0.509
FM-HC	0.950	0.301	1.599	0.00214
FM-CLBP	0.638	0.086	1.191	0.0194
Sleep Duration
CLBP-HC	-0.226	-0.751	0.298	0.56
FM-HC	0.350	-0.160	0.860	0.236
FM-CLBP	0.576	0.142	1.010	0.00593
Sleep Efficacy
CLBP-HC	-0.444	-1.334	0.445	0.462
FM-HC	-0.050	-0.914	0.814	0.99
FM-CLBP	0.394	-0.342	1.130	0.413
Sleep Disturbance
CLBP-HC	0.100	0.006	0.194	0.0353
FM-HC	0.100	0.008	0.192	0.0293
FM-CLBP	0.000	-0.078	0.078	1
Sleep Medications
CLBP-HC	0.168	-0.612	0.947	0.866
FM-HC	1.125	0.367	1.883	0.00183
FM-CLBP	0.957	0.312	1.603	0.00185
Sleep Daytime Functioning
CLBP-HC	-0.203	-0.459	0.053	0.147
FM-HC	-0.225	-0.473	0.023	0.0841
FM-CLBP	-0.022	-0.234	0.190	0.967
PSQI Global
CLBP-HC	0.171	-1.960	2.302	0.98
FM-HC	3.175	1.104	5.246	0.00125
FM-CLBP	3.004	1.240	4.768	0.000305
ESS Total
CLBP-HC	1.344	-1.094	3.782	0.391
FM-HC	2.300	-0.069	4.669	0.059
FM-CLBP	0.956	-1.062	2.974	0.499
ISI Total
CLBP-HC	4.171	0.547	7.794	0.0199
FM-HC	10.250	6.728	13.772	2.19e-09
FM-CLBP	6.079	3.080	9.079	1.64e-05
BDI Total
CLBP-HC	8.291	2.742	13.840	0.0017
FM-HC	12.175	6.782	17.568	1.72e-06
FM-CLBP	3.884	-0.710	8.477	0.114
McGill Total
CLBP-HC	28.174	19.512	36.835	5.02e-10
FM-HC	33.175	24.757	41.593	4.64e-10
FM-CLBP	5.001	-2.169	12.171	0.225
Time in Bed
CLBP-HC	-4.024	-11.441	3.393	0.403
FM-HC	-3.724	-10.932	3.484	0.438
FM-CLBP	0.300	-5.840	6.439	0.993
Note:
Red = Significant group tests (p ≤ 0.05)

END - BEYOND HERE IS EXPLORATORY

Brad PT

Jason